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Download&Category Slug= 33 Verschueren et al. Reproductive Health (2020) 17:62 https://doi.org/10.1186/s12978-020-0902-7 RESEARCH Open Access Childbirth outcomes and ethnic disparities in Suriname: a nationwide registry-based study in a middle-income country Kim J. C. Verschueren1* , Zita D. Prüst1, Raëz R. Paidin2,3, Lachmi R. Kodan1,4,5, Kitty W. M. Bloemenkamp1, Marcus J. Rijken1,5 and Joyce L. Browne5 Abstract Background: Our study aims to evaluate the current perinatal registry, analyze national childbirth outcomes and study ethnic disparities in middle-income country Suriname, South America. Methods: A nationwide birth registry study was conducted in Suriname. Data were collected for 2016 and 2017 from the childbirth books of all five hospital maternity wards, covering 86% of all births in the country. Multinomial regression analyses were used to assess ethnic disparities in outcomes of maternal deaths, stillbirths, teenage pregnancy, cesarean delivery, low birth weight and preterm birth with Hindustani women as reference group. Results: 18.290 women gave birth to 18.118 (98%) live born children in the five hospitals. Hospital-based maternal mortality ratio was 112 per 100.000 live births. Hospital-based late stillbirth rate was 16 per 1000 births. Stillbirth rate was highest among Maroon (African-descendent) women (25 per 1000 births, aOR 2.0 (95%CI 1.3–2.8) and lowest among Javanese women (6 stillbirths per 1000 births, aOR 0.5, 95%CI 0.2–1.2). Preterm birth and low birthweight occurred in 14 and 15% of all births. Teenage pregnancy accounted for 14% of all births and was higher in Maroon women (18%) compared to Hindustani women (10%, aOR 2.1, 95%CI 1.8–2.4). The national cesarean section rate was 24% and was lower in Maroon (17%) than in Hindustani (32%) women (aOR 0.5 (95%CI 0.5–0.6)). Cesarean section rates varied between the hospitals from 17 to 36%. Conclusion: This is the first nationwide comprehensive overview of maternal and perinatal health in a middle income country. Disaggregated perinatal health data in Suriname shows substantial inequities in outcomes by ethnicity which need to be targetted by health professionals, researchers and policy makers. Keywords: Perinatal registry, Maternal mortality, Stillbirths, Middle-income country, Suriname, Ethnicity, Racial, Disaggregate Plain English summary represents 86% of all national births in Suriname. There In middle-income country Suriname we studied all hospital were 20 maternal deaths, resulting in a maternal mortality births to describe childbirth outcomes and to discover in- ratio of 112 per 100.000 live births. There were 285 still- equities by ethnicity. In 2016 and 2017, 18.290 women gave births beyond 28 weeks of gestation, resulting in a late still- birth to a baby in either of the five hospitals, which birth rate of 16 per 1000 births. Stillbirth rate was highest in Maroon women (25 per 1000 births) and lowest in Ja- * Correspondence: [email protected] vanese women (6 per 1000 births). Teenage pregnancies 1 Division Women and Baby, Department of Obstetrics, Birth Centre accounted for 14% of all births, was highest in Indigenous Wilhelmina’s Children Hospital, Utrecht, The Netherlands Full list of author information is available at the end of the article (21%) and Maroon (18%) women, and lowest in Hindustani (10%) and Chinese (3%) women. Babies with low birth © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Verschueren et al. Reproductive Health (2020) 17:62 Page 2 of 14 weight accounted for 15% of all births and were most fre- such as wealth, education, age and place of residence. Sev- quently seen in Hindustani women (18%). The cesarean eral studies in high-income countries have shown that section rate was 24%, but varied from 17 to 36% between women of African descent experience a two to six times the five hospitals. Hindustani women were almost twice higher risk for severe maternal outcomes compared to more likely to receive a cesarean section than Maroon Caucasian women (often linked to socio-economic fac- women (32 vs. 17%). Disaggregating perinatal health data is tors) [12–16]. Suriname is particularly of interest as it has encouraged to identify and help target inequity within the multiple ethnic groups without one great majority [17]. health system. In conclusion, there are substantial inequi- To promote an efficient and adequate implementation ties by ethnicity with Maroon women experiencing the process of the new perinatal data system in Suriname highest risk on adverse outcomes (maternal mortality, and subsequently evaluate its effect, this study provides stillbirth, increased preterm birth, low apgar score). The a baseline assessment of perinatal data from all hospitals inequitable access to care experienced by women of in the country. Our study aims to evaluate the current African-descent requires policy makers to review possible perinatal registry, analyze national maternal and peri- interventions. natal characteristics and study ethnic disparities in child- birth outcomes in Suriname. Background Maternal and perinatal vital registration systems are es- Methods sential to monitor outcomes of pregnant women and their Study design offspring, identify inequities in service provision and A two-year registry-based nationwide study of all hos- health outcomes and facilitate quality control in perinatal pital births was conducted, using the childbirth books of care [1, 2]. Following lessons learned from the Millennium the five maternity wards between January 1st, 2016 and Development Goals (MDGs), the Sustainable Develop- December 31st, 2017. ment Goals (SDGs) call for statistics “disaggregated by income, gender, age, race, ethnicity, migratory status, dis- Study context and ethnicities ability, geographic location and other characteristics rele- Suriname is a multi-ethnical, upper middle-income country vant in national contexts” to monitor progress and on the northeast coast of South-America. With an esti- identified inequities in health outcomes [2–4]. mated population of 598,000 people, it is one of the least The Global Strategy for Women’s, Children’sandAdo- populous countries in the Americas [18, 19]. Ethnical dis- lescents’ Health, 2016–2030 is a roadmap for ending all tribution among the general Surinamese population in preventable maternal and newborn deaths (including still- 2013 was: Hindustani (27%), Maroon (22%), Creole (16%), births) and is central to the achievement of the SDGs [5]. Javanese (14%), Mixed (13%), Indigenous (4%), Chinese This strategy urgently calls for the extension and strength- (1%) and Other (3%) [19, 20].DiversityinSurinameisare- ening of health information systems to generate high qual- flection of the country’s history. Indigenous people, also ity data and evidence to measure progress and be able to known as Amerindians, are the original inhabitants of the reach the target of a global maternal mortality ratio country. Maroon and Creoles are African-descendants who (MMR) under 70 per 100.000 live births and stillbirth rate were enslaved and brought to Suriname in the seventeenth (SBR) under 12 stillbirths per 1000 births [2, 6]. and eighteenth century. Maroon people, in contrast to Cre- National childbirth registries have been established in oles, escaped into the interior of the country. Creoles several high income countries [7–9]. Low and middle- gained their freedom in 1863 when slavery was abolished income countries (LMIC) are increasingly investing in ro- in Suriname and often have mixed African - European bust national information on maternal and perinatal (Dutch and British) ancestry. Asian-descendants: Hindu- health indicators for SDG monitoring. However, given the stani (from East-India), Javanese (from Indonesia, then a complexity of establishing a well-functioning registry sys- Dutch-ruled colony) and Chinese people, came to tem, data collection in these countries is often not uni- Suriname in the late nineteenth century as contract form, lack important indicators and data are frequently workers. Mixed people are the result of interchanging missing [1]. In many (currently, 34) Latin American and identities between almost all ethnicities. Other ethnic- Caribbean countries, the Perinatal Information System ities include mostly Brazilians, Caucasians (descen- (SIP), a digital clinical record and local management soft- dants of Dutch colonists) and few Lebanese [17]. ware standard has been implemented [10]. Suriname, an upper middle-income country, is one of the countries Study setting where SIP will be re-launched after a previous attempt in The study was conducted in all hospitals in Suriname: four 2014, which failed for unknown reasons [11]. hospitals located in the capital Paramaribo and one hospital Ethnic disparities in birth outcomes have modestly been in Nickerie (West coast). Institutions perform approxi- studied compared to other social determinants of health, mately 92% of all births in Suriname with approximately Verschueren et al. Reproductive Health (2020) 17:62 Page 3 of 14 86% in hospitals and 6% in primary health care centers. In- as the number of late stillbirths per 1000 births beyond formation regarding the primary health care births, home 28 weeks of gestation (or > 1000 g) [28].
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